[P]Rehab Clinical Pearl: Bridge Progressions

The bridge is probably the single most prescribed exercise by physios…it seems that the bridge exercise is ubiquitous with physical therapy and rehab. As you may be suspecting, we think this is a pretty bad thing! Yes – the bridge is in fact a decent exercise that can help groove a hip hinge movement pattern and can be the starting place for a host of pathologies ranging from the lumbar spine all the way to the foot and ankle. But that doesn’t mean that our clients need to perform 3 sets of 10 bridges for months on end during the course of their rehab!

Our library has tons of exercises to help groove the horizontal hip hinge movement pattern, starting from the basic supine bridge all the way to a loaded barbell hip thrust. The template we will be discussing is Double Leg Bridge Progressions.

 

Teaching The Bridge: Where To Start

When teaching someone a bridge, I will usually start with either a supine bridge or a bridge hold. Why one or the other? First off, let’s discuss the supine bridge. The supine bridge is the most basic supine horizontal hip hinge movement and the best way to teach a hip hinge within this supine constraint. However, if my goal is to teach someone to feel their glutes or improve body awareness in a horizontal hip hinge pattern, then I will opt for the bridge hold first. Isometrics are a great way to cue individuals into feeling the proper muscles working, as you can ramp up the effort to near 100% by encouraging your clients to drive through the ground as hard as possible. Internal cueing is great for developing a mind-body connection!

 

If not constrained to the floor, a tall kneeling hip hinge is one of my favorite ways to teach someone to hip hinge. Eliminating a degree of freedom (a joint moving…in this case the foot/ankle joint), allows our clients to better isolate the movement from just their hips rather than their knee or low back. Adding a band as an external resistance cue to push against is a very easy way to further drive home this movement pattern for someone that is struggling with it. We have tons of other tall kneeling hip hinge variations in the library that you can check out too!

 

 

Using Levers To Target The Hamstrings

The hip extension movement within the bridge will utilize the body’s primary hip extensors in a relatively neutral position: the glute max and the hamstrings. While both contribute to active hip extension, only the hamstrings contribute to active knee flexion. Thus, we can change our foot placement of the traditional bridge to increase the internal moment of the hamstring muscle group’s contribution to active knee flexion! Typically, this is accomplished by either setting up the feet further from the hips or by placing the feet on an elevated surface!

 

When & How To Use Bands To Your Benefit

Without changing the movement pattern, we can easily recruit the glute max to a greater degree by calling upon it’s other two primary muscle actions: hip abduction and external rotation. This can easily be accomplished through the use of resistance band tubing. Our favorite is the Hip Halo (use code PREHAB15 for 15% off), which is shown in the videos. We have both an isometric bridge + isotonic hip abduction and an isotonic bridge + isometric hip abduction. Play around with both variations with your clients!

 

 

No bands? No problem!

If your clients don’t have a band at home, they can try out the frog bridge. The key in this one is that you are actively trying to spread an invisible band and push into maximal hip abduction + external rotation.

 

 

Bridge With Extra Adductor Activation

Working in the exact opposite fashion, we also have an isotonic bridge with isometric hip adduction. This one really fires up the hip adductors, which also play a big role in hip extension at higher degrees of hip flexion (adductor magnus). This is a popular technique for therapists that are looking to work on sacroiliac joint force closure after a SIJ MET, which we also have in the library. Remember, if there is a technique or exercise we do not have in the library, simply request it and we will film it!

 

 

Bridge for Spine Articulating

I am a big fan of spine articulating, especially into flexion, for any flexion sensitive low back patients. This is especially true for those that have chronic low back pain and have simply lost the ability to flex through their lumbar spine. We have a ton of “segmental” exercises in the [P]Rehab Exercise library, and including this segmental version of the bridge. The key is to really focus on a posterior pelvic tilt at the start of the motion, letting the pelvis guide the lower lumbar into flexion – rather than just focusing on a PPT at the top of the motion.

 

Progressing to a True Single Leg Bridge

You may be able to progress directly from a double leg bridge to a single leg bridge if your client has the requisite lumbo-pelvic control and hip strength to control a single leg bridge with a level pelvis. If they do not, the following two variations are a great way to slowly build up the strength and control required of a pristine single leg bridge! In the staggered bridge below, remember to cue the leg closest to the body to do most of the lifting into hip extension. You can slowly cue your client to push less and less through the foot that is further away. Now, if you were progressing someone’s hamstring loading, the cueing would actually be the opposite 🙂

The bridge march is actually a true isometric single leg bridge, albeit for a split second. This is a great way to “bridge” someone to an isotonic single leg bridge (like what I did there?!) In this example, you’ll notice that Arash lifts his entire contralateral foot off the ground. A micro progression of this would be to just lift the heel off the ground while continuing to push as much as needed through the forefoot. This same march can be performed on an elevated surface if the goal is to hit the hamstrings more. Again, it’s all about micro-changes so our clients can find success in their programs!

 

 

Single Leg Bridge Options

Once your client is able to progress to a single leg bridge, one of the most common questions I get from my clients is “what do I do with my other leg”? While there is no wrong answer to this question, understand that the other leg provides a “heavier lower body” to the working hip! Meaning, progressing from the contralateral leg bent, to crossed, to straight out is the most linear progression from easiest to hardest.

I know many clinicians that like to have their clients “hug” their opposite knee to promote a posterior pelvic tilt. This is definitely a feasible option!

If I have a client who is struggling with their lumbo-pelvic control in a single leg bridge with the leg straight out, oftentimes I will regress to the crossed leg version above rather than make a bigger macrochange to some form of a staggered bridge. The straight leg bridge I consider the “gold standard” of a supine single leg bridge as it’s not only the hardest, but we get to work on the contralateral hip flexors simultaneously.

Once your client has mastered a single leg bridge, it can be used as a fantastic objective assessment for comparison of side to side differences in strength/motor control. The Single Leg Bridge Endurance Test is a reliable tool developed and used to evaluate proximal lower body strength, pelvis and trunk control, and muscle endurance. Please watch the video to get a visual demonstration of how to perform the test and what to be mindful of. We have a lot of other assessments in the library that you can check out under the “assessments” tab!

 

Reverse Bridge Variations

The next two variations shown are examples of a thoracic spine bridge. It’s essentially a bridge in a reverse tall plank position where the upper body is completely off the ground. In order to accomplish this movement successfully, you have to keep one of your hands on the ground behind you and rotate your thorax ipsilaterally. It’s a great way to work on active thoracic spine rotation.

The bear to high single leg bridge position exercise is very similar to the more mobility-focused thoracic spine bridge except that it starts from a bear position. I typically like this combo movement as part of a dynamic warm-up!

 

 

The Bridge As A Base Position

The bridge position can be used as a base position as well! When performing upper extremity tasks, typically we must derive stability proximally. Usually, we think of this as coming from this scapular muscles or core, but this can also extend to the glute as well! A prime example of this would be in the example below. You need good activation through the glutes in order to stay stale during the floor press. During COVID quarantine this was my way of mimicking the torso angle of a decline bench press without a decline bench!

Once a single leg bridge with the leg straight is mastered, you can have your clients perform one of my favorite early-stage rehab exercises. Essentially we are combining a straight leg raise with an isometric single leg bridge! In the early stages of rehab, one of the biggest obstacles we face is disuse atrophy. If I have a post-op R knee client, for example, and they have gotten down the traditional supine straight leg raise, I will now have them perform it in a single leg bridge position! Now we are hitting our primary goal of quadriceps activation while also combating disuse atrophy on the contralateral limb.

 

The Hip Thrust

Now, onto the mack daddy of them all…the hip thrust! The hip thrust is great for targeting the largest muscle of the body, the Gluteus Maximus. When looking at EMG activity of muscles during a hip thrust we see great activation of the hamstrings, quadriceps, and adductors as well; making this exercise a great bang for your buck movement! I have seen the hip thrust performed all kinds of ways, below Arash shows you how he likes to perform the traditional hip thrust with the goal of biasing the posterior chain muscles. We have a great podcast episode with Bret Contreras that you can check out HERE where he covers everything you need to know about the hip thrust and its origins!

You’ll notice in this example that we do not have a hip thruster. We are going to assume that most of your clients do not have one too! Thus, its essential to first teach your clients how to properly set up on a traditional bench! This video below that I put together will go over not only proper set up, but also the execution of a proper hip thrust!

Now onto different hip thrust variations. Typically if your client is able to perform a hip thrust we are beginning to load up that hip extension movement. If your client doesn’t have a barbell handy, there are a few other ways that we can add load through bands and dumbbells that we will highlight below. All of the same concepts we discussed for the supine bridge apply to the hip thrust!

 

 

 

 

Hopefully, we’ve helped show you a few new variations of the traditional old bridge that you can begin implementing today with your clients!

 

Clinician: Michael Lau, PT, DPT, CSCS